Political myth-making about America’s rural “heartland” is doubly pernicious, increasing rural vulnerability to COVID-19 and ignoring the disintegration of rural health services.
In March 2020, Fairmont Regional Medical Center, the only hospital in Fairmont County, West Virginia, closed its doors amid increasing financial strains. Later that month, an ambulance was called to take an 88-year-old woman infected with COVID-19 to the hospital. Instead of making the usual two-minute drive to Fairmont Regional, the ambulance had to drive 25 minutes to the next-nearest facility. Days later, the woman became West Virginia’s first reported coronavirus death (Healy et al. 2020). While some may point to the woman’s age as a deciding factor in her declining health and eventual death, her fate more aptly underscores how the public health infrastructure in rural regions is potentially the most fragile aspect of the rural health care continuum.
As the total number of COVID-19 cases in the United States surges past 1.5 million, much of the focus in news media and discussions among national experts has long been on large, urban metropolitan areas. The rationale is that their dense populations engaging in frequent interpersonal contact are at heightened risk of contracting the disease. When rural areas have been the focus of stories of community spread, the vectors of infection were often wealthy urbanites fleeing rising case counts in the city. The county commissioner of Tillamook County, Oregon, for example, took to the pages of the Washington Post opinion section to convey what he described as a “plea from rural America,” urging “COVID-19 urban refugees” to stay home. “Thousands of urban visitors descended on our villages, with cars lined up for miles on highways to the coast,” he wrote.
In South Dakota, one of five states that have remained “open,” Governor Kristi Noem defended her decision to not issue stay-at-home orders by explicitly distinguishing her state from a dense, urban hotspot in moral, political terms. “South Dakota is not New York City,” Noem said in a press conference on March 30. “Our sense of personal responsibility, our resiliency and our already sparse population density put us in a great position to manage the spread of this virus without needing to resort to some of the measures that we’ve seen in some of these major cities, coastal cities and other countries.” The governor characterized China’s response as “draconian” and dismissed strict European stay-at-home orders as actions that “limit citizens’ rights.” She would later clash with tribal leaders over their decision to erect COVID-19 checkpoints at reservation borders, and to install their own contact tracing mechanisms.
President Trump has mobilized these imagined immunities by indicating that the restrictive quarantine measures aren’t necessary in rural America. “If you look at Montana, Wyoming, North Dakota—that’s a lot different than New York, it’s a lot different than New Jersey,” Trump said during a coronavirus task force briefing on April 16. He insisted, too, that the regions should be viewed as models for reopening the country. Two weeks earlier, on March 28, Trump had considered enforcing quarantine on New York, New Jersey, and Connecticut, alluding to such actions as necessary measures for protecting rural “red” America from infection exported by East Coast “blue” states. “They go to Florida and a lot of people don’t want that,” he said.
Tracing the rhetoric of imagined immunities further exposes the racialized character of the moral distinctions between rural and urban risk. The rural West figures prominently as exceptional and exemplary, reanimating key national political and moral dramas that pit weak, selfish urban Northeast against the rugged rural West. The imagined immunity of rural America omits entire swathes of rural land in the South and Midwest, where many Black and Latino people reside and work; they do not include the rural residents of Native reservations; they do not recognize the vast influence of prison economies throughout rural America. Acknowledging these sites of rural risk would also require acknowledging the links among health care, race, and labor in what Adam Serwer (2020) has called the COVID-19 clause of the United States’ racial contract: “The lives of disproportionately black and brown workers are being sacrificed to fuel the engine of a faltering economy, by a president who disdains them.”
Even though rural areas currently have fewer coronavirus cases per capita, both cases and deaths are growing at a faster rate compared to metro counties; as of May 3, more than 60 percent of the smallest counties had at least one case (Fehr et al. 2020). Operating with already limited resources while serving populations with high levels of mortality and morbidity, rural health systems experienced drastic reductions in hospitals and available workforce, lowered Medicare reimbursement systems for rural providers, and a rise in consolidation of health care delivery through the formation of care alliances and networks. Market-driven changes in the 1990s toward managed care principles and an emerging emphasis on corporate and business philosophies significantly impacted health care delivery everywhere, but their effects in rural areas were experienced differently because there were fewer possibilities for cutting costs while increasing profits within rural markets (Ricketts 2000). Rural health systems changed more as a result of the increased integration and assimilation of providers and institutions into systems and networks in order to confront ongoing legislative, regulatory, and fiscal challenges. However, the enduring problem of resource distribution remains the hallmark of rural health care.
The 2010 Affordable Care Act (ACA) was designed to provide much needed relief to rural health systems, with new funding earmarked for community health centers and hospitals and increased reimbursement rates for primary care providers. However, many states with large rural populations, mostly in the South—Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, Tennessee, and Texas—did not adopt Medicaid expansion under the ACA. Medicaid expansion, which has a 90 percent federal matching rate, offers states the capacity to care for poor uninsured residents, the majority of whom are Native, Black, and Latino.
States that did not expand Medicaid will face the current COVID-19 crisis with considerably fewer federal resources as more people become uninsured and sick. Researchers at the Commonwealth Fund found that expansion states will receive approximately $557 more in federal funding per resident than nonexpansion states through the new Coronavirus Aid, Relief, and Economic Security (CARES) Act (Mann 2020). Further, labor economists and investment banks have predicted that the US unemployment rate, which surged to nearly 15 percent in April, could increase to 25 percent this year, comparable to the peak jobless rate experienced during the Great Depression (Ivanova 2020); as millions of people lose their jobs and incomes because of the crisis, they will also lose their health insurance. In states which have not expanded Medicaid, millions of people will not qualify for similar coverage options, and become uninsured, leaving them even more vulnerable under the current crisis.
But the ACA has not been a watershed moment for rural regions. Sangaramoorthy’s (2018) work on the Eastern Shore, for instance, brings to the forefront how the ACA continues to uphold existing uneven geographies of access to health care. Under the ACA, there has been noted growth both in the number and capacity of health centers due to increased patient revenue from Medicaid expansion and private health insurance as well as federal investment (Rosenbaum et al. 2017). However, even with such progress in coverage, many of those who utilize health centers remain uninsured or underinsured because of increased cost sharing associated with insurance plans or because they do not qualify to take part due to income or immigration restrictions (Sangaramoorthy 2017; 2018). Furthermore, insufficient funding, insurance reimbursement, and workforce recruitment and retention remain critical challenges for rural health centers, including hospitals, as the Fairmont Regional story suggests.
The imagined isolation of rural areas also directs attention away from the racialized labor dynamics shaping COVID-19 infection. Rural residents often travel long distances for work to nearby cities or towns. Forms of employment available to rural residents are concentrated in industries—agricultural and food procurement and processing, manufacturing, natural resources and mining, and leisure and hospitality—where it is nearly impossible to work remotely and where few labor protections such as sick leave and time off exist (Pender et al. 2019). Deemed “essential” during the pandemic, many such workers have been ordered to work, even as stay-at-home orders are put in place. In the agricultural and food processing sectors, which heavily rely on Black and Latino workers, many are working in close quarters, leaving them vulnerable to COVID-19 infection. The Centers for Disease Control and Prevention (CDC) recently released data stating that more than 4,900 workers in meat processing plants, mainly people of color, have been diagnosed with COVID-19, with South Dakota, Iowa, Wisconsin, Washington, and Delaware having the highest percentages of confirmed cases among workers across different plants. Many of these workers also live in crowded, multigenerational households and sometimes share transportation to and from work, contributing to increased risk for transmission of COVID-19 outside the facility (Dyal et al. 2020).
Much like urban environments, the density of social networks and frequency of social contacts can also be highly complex for those living in rural regions. Close-knit communities and social gatherings large and small are commonplace. Albany, Georgia, a small town three hours south of Atlanta, gained notoriety as a hotspot for COVID-19 after many who attended a large funeral in late February fell ill and eventually died. In Magnum, the largest city in Greer County, Oklahoma, located in the western part of the state and with a population of about 6,000, people who gathered regularly at the local church and nursing home fell ill, and some eventually died. The county now has one of the highest infection rates among non-metro areas.
As the pandemic shows signs of slowing in regions with early case detection and rapid public health response, we continue to see a rise in cases and fatalities among residents of rural areas in “America’s heartland.” Moral and political dramas aligned with national myth-making about rural areas have heightened rural vulnerability to COVID-19, as they have also occluded the slow, steady dismantlement and decline of rural health systems.
Thurka Sangaramoorthy is an associate professor of anthropology at the University of Maryland. She is the author of Treating AIDS: Politics of Difference, Paradox of Prevention (2014) and co-author of Rapid Ethnographic Assessments: A Practical Approach and Toolkit for Collaborative Community Research (2020).
Adia Benton is an associate professor of anthropology and African studies at Northwestern University. She is the author of HIV Exceptionalism: Development through Disease (2015) and is currently writing a book about the 2014–2016 West African Ebola outbreak.
Charlotte Hollands created artwork as well as spot illustrations of experiences from social distancing life for AN’s pandemic issue. Hollands is an illustrator, artist, and ethnographer who is developing new ways to use illustration within social science research and is currently completing her first graphic nonfiction book, written by Alisse Waterston.
Cite as: Sangaramoorthy, Thurka and Adia Benton. 2020. “Imagining Rural Immunity.” Anthropology News website, June 19, 2020. DOI: 10.1111/AN.1439